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Orientation

Understanding the needs of your LGBT patients

The New Physician November 2007
Elderly patients may react differently to certain medications than do younger patients. Blacks are at higher risk for stroke than whites. Children require a whole series of immunizations just for childhood diseases.


Understanding the special needs of different patient populations is a part of good clinical care and good medical training. When it comes to the needs of patients who are lesbian, gay, bisexual or transgender (LGBT), however, awareness and sensitivity to these special needs are often lacking, both because training is absent and, all too often, clinicians aren’t aware which of their patients are part of this population. And that means that LGBT patients are not getting optimal care.


Unfortunately, the subject of LGBT health care often launches with a discussion of STDs, but that is only a small part of the picture. Of course, gay men and men who have sex with men are at higher risk for a variety of sexually transmitted diseases, including HIV/AIDS, hepatitis and anal papilloma. And although lesbians are generally not considered at high risk for most STDs, HPV and genital herpes are easily transmitted between women during sex, and many contract bacterial vaginosis, especially those under age 30. But the LGBT population has more to worry about than just STDs.


Rates of substance abuse (alcohol, tobacco and other drugs) are higher in the LGBT community than in the general population. Depression also takes a particularly harsh toll among LGBT people, especially adolescents, those who are still in the closet and those who do not have a good social support network.


Violence, too, affects this population disproportionately. According to the National Coalition for LGBT Health, 47 percent of lesbians have experienced repeated acts of domestic violence, and two in every five gay and bisexual men experience abuse with an intimate partner, about the same as domestic violence rates for heterosexual women. A survey from the National Coalition of Anti-Violence Programs (NCAVP) found that 50 percent of transgender individuals had been raped or assaulted by a romantic partner.


And, of course, the violence is not always domestic. The NCAVP’s 2007 annual report documented 1,440 violent anti-LGBT incidents nationwide in 2006.


Research also shows that breast and ovarian cancer are more prevalent in lesbians, though it is not clear why, and transgender individuals are at higher-than-average risk from reproductive cancers, at least in part because they have difficulty accessing care and early detection, and because they often feel discomfort with routine procedures involving reproductive health.


Even workaday wellness issues such as diet and fitness require a unique emphasis in the LGBT community. Lesbians, on average, have a higher body mass index than heterosexual women, putting them at greater risk for heart disease, cancers and diabetes. Gay men are more likely to have problems with body image than straight men, which can lead to abuse of steroids. Eating disorders are also more common in gay than straight men, leading to a spectrum of related health problems.


Handling these specific needs is not terribly tricky from a clinical perspective, although some, like depression and eating disorders, can be difficult to identify and may require a team approach to treatment, and social issues, such as domestic violence, can require a high degree of sensitivity. But in order to start to address these health concerns, the physician has to know the patient. And that, with regard to LGBT patients, is most definitely the rub.


“Discussions of sexual health and sexual orientation are essential to understanding the needs of all patients,” explains Dr. Henry Ng, lead physician at Cleveland’s MetroHealth Medical Center’s PRIDE Clinic, a comprehensive primary care medical home for LGBT patients. All too many physicians are poorly trained, uncomfortable or simply unaware of their own presumptions when it comes to taking a sexual history or otherwise discussing sexuality with their patients, Ng asserts. But getting this right goes beyond being culturally sensitive: “This is a standard of care, but it is often neglected—or worse yet, performed poorly with heterosexual bias.” But why do otherwise caring and competent physicians get this so wrong?


Don’t Ask, and They
Might Not Tell



The short answer is that many physicians just aren’t comfortable taking a sexual history. In fact, just like many nonphysicians, they can be uneasy with LGBT people and do not really want to talk about it. And fearing a negative response from the physician, patients can feel awkward, too. But getting past this little dance of discomfort is absolutely essential for good health care for LGBT patients.


Dr. Nelson F. Sanchez, a third-year resident in internal medicine at New York University, is lead author of a study, published in the January 2006 issue of Family Medicine, gauging medical students’ ability to care for LGBT patients. His research found that the more clinical exposure students had to these individuals, the more likely they were to get a comprehensive history, have good attitudes toward the patients and have adequate knowledge of the attendant health-care issues. That familiarity is key to taking a thorough and useful history.


However, even the students with high self-reported comfort levels did not always take a comprehensive history, and even in the group of students with prior exposure to LGBT patients, only 49 percent routinely asked about an intimate partner, and 81 percent never or rarely asked patients’ permission to document sexual history in their charts—an important and often overlooked option, according to Sanchez.


“Sometimes it’s just a matter of invisibility,” says Dr. Ken Haller, past president of the Gay and Lesbian Medical Association (GLMA) and associate professor of pediatrics at Saint Louis University School of Medicine. “It just doesn’t occur to people. Straight doctors just don’t think to ask.”


But they should, Ng insists. “Providers should routinely ask about sexual orientation, sexual behaviors and domestic violence, just as they ask parents about their children’s development or ask their adult patients about signs and symptoms of heart disease.”


Set the Right Tone


It’s one matter to agree that physicians need to ask the questions; it’s another to know how to go about asking.


“Thus far, there is no standardized manner to obtain [an LGBT] history,” says Ng. One potential tool is the intake form, he suggests. Forms that include gender-neutral terms and offer more than two choices for gender and sexual orientation “can signify that [these] issues are important to that provider and practice.”


Dr. Stephen Smith, professor of family medicine at the Warren Alpert Medical School of Brown University, agrees. “Putting sexual preference on patient questionnaires would be a good thing, as would changing ‘sex’ options to more than just male/female so as to include transgender persons,” says Smith. But conversation is still key. “When talking with patients, I ask if they are sexually active with men, women, or both. I believe this lets them know that I am sensitive and open to the issues and would encourage them to be open with me. I think this is a better approach than specifically asking them ‘Are you straight or gay?’ which puts the patient on the spot without yet knowing how you, the doctor, will react to the answer,” Smith adds.


Getting the tone right when asking the questions is essential as well. “It is important for the physician to always come from a nonjudgmental place during the medical history,” believes Rob McDonald, a fourth-year at the University of Alabama at Birmingham School of Medicine (UAB). “Being nonjudgmental comes through in an intangible but perceptible way during conversation, and that facilitates a good relationship and an optimal assessment,” he says.


Haller agrees: “It is important for physicians to understand how much power they have in validating patients’ issues. Having [the right questions] on the intake forms normalizes [the patient’s sexuality],” he says, and discussing it openly helps create a comfortable relationship between the doctor and the patient.


Of course, talking about sexuality—any kind of sexuality—rarely is a simple matter. One gay student at a Northeastern medical school who asked not to be named says it’s not easy for him, either. But he does offer some advice to straight doctors who are struggling with this. “It is important,” he says, “not to equate homosexuality in men, for instance, with anal sex and/or HIV. To be gay means more than just the sexual geometry or how things fit together—or not. I hope that the new generation of physicians knows that sexuality is more than just sex. There’s a whole culture and set of ideals behind it. The important thing is not to assume anything. If the patient isn’t backed into a corner by imposition of a given sexual orientation or assumptions about a particular lifestyle, then the interview will be more comfortable for both.”


Running Interference


Just as LGBT people often are called a community, medical people operate within a community as well, and it includes a host of professionals, from clinical specialists to psychologists, nurses and social workers. Very often, the primary care physician who has made an effort to establish an open and understanding relationship with his LGBT patients will have to be an advocate for these patients in the larger medical community.


Liz Galst, a lesbian and the birth mother of two young children, had an almost ideal situation with the OB/Gyn practice that delivered her babies. “The practice is very gay-friendly,” says Galst. “The hospital staff were great, too, but they were a little confused.” In New York, where Galst and her family live, her partner was able to adopt the children in what is known as a “second-parent adoption.” However, the adoption is not completed until after the baby is born, and the birth-certificate form lists only two options: single and married. When their second child was born, since Galst had not named a father on the birth certificate, the hospital staff listed her as a single mother and assigned a social worker to the case, even though she was not single at all, and her partner was with her throughout the birth.


Situations like these, of course, do not have an impact on physical health (although conceivably could contribute to gays’ and lesbians’
higher rates of depression), but they are areas in which a sensitive, supportive physician can help by, as Galst puts it, “running interference” for your patients in the larger medical community.


You may also need to intervene in your own education. In most medical schools, the curriculum won’t be much help. When Smith was in medical school from 1968 to 1972, “there was no discussion of sexual preference and almost no discussion of sex, period,” he says. Smith developed a sensitivity to these issues after he got out of medical school by attending workshops developed by the American Medical Student Association. Education about LGBT issues still varies wildly from school to school; there is no curricular requirement from the Association of American Medical Colleges on this one. “There is a mandate in most medical schools to be ‘culturally competent,’ but this can be interpreted in many ways,” says Haller.


Dr. Ricky Y. Choi got his medical degree in Charleston, South Carolina, a conservative community with a school having what Choi calls a “frankly homophobic staff.” He became acquainted with LGBT people only during his residency at the University of California, San Francisco (UCSF). “While I did have some LGBT patients [at UCSF], interestingly, I had more kids with LGBT parents. I also had LGBT co-residents, some of whom had young families of their own. I can’t say that it changed the way I practiced, but it did help me see LGBT families as part of regular society—an important and valuable part of society, where children can thrive,” he says.


Not all schools totally drop the ball on this one, though. McDonald says that his school, UAB, “does a reasonable job of teaching LGBT issues. Particularly on World AIDS Day, [when] speakers make special efforts to convey to students that there are additional health risks associated with being homosexual, including substance abuse and psychiatric issues related to the difficulties of not being accepted by ‘mainstream’ society.”


Alison Reid, a third-year at Johns Hopkins University School of Medicine, has a “pretty high comfort level” with LGBT patients. Hopkins, says Reid, offers a unit on sexuality in which LGBT issues are briefly but nicely covered. “There was a very good lecture on transgender communication. For the most part, those who wanted to got a lot out of it.”


Most of Reid’s training came outside the classroom, however. She worked as an HIV counselor in a clinic where 80 percent of her patients were gay, and she was trained in taking a sexual history for this job. The training included small group sessions and role-playing, she says.


If your school does not offer resources for learning about LGBT health care, you might have to take matters into your own hands. “If you are in an area without clinics that target the LGBT population,” Sanchez says, “schools should offer scripted encounters to give students practice.” And when schools don’t, students should speak up and ask for it.


“You have to make a strong argument to effect change,” he asserts. “Get in touch with gay and lesbian groups on campus. Find out what other schools are doing and see if you can mimic it. Gather evidence and look for faculty support. Get deans and professors on your side. You’ll have to find someone willing to teach it.” Sanchez adds, “In some places, students teach each other.”


Getting the training and exposure you need to provide high-quality health care to LGBT patients may take a little effort. But it is worth it. Knowledge and experience will make you comfortable, and, says Reid, “If the provider is comfortable, the patient will be, too.” Having patients you are at ease with treating and who are relaxed and open with you can help nourish your joy in medicine. After all, you got into this field because you wanted to help people—and there is a rich variety of people out there.
Avery Hurt is a freelance writer in Birmingham, Alabama.
Direct comments about this article to tnp@amsa.org.